Hospital Fined for Wrong-Site Surgery

Rhode Island Hospital, located in Providence, will pay $150,000 and install video cameras in all of its operating rooms after performing its fifth wrong-site surgery since 2007, according to the state's Department of Health.

The hospital will also have to open its ORs to an inspector who will observe surgical procedures and protocols for at least a year, the department said.

On Oct. 22, Rhode Island Hospital notified the Department of Health that it had performed a wrong-site procedure on a patient who was scheduled to have elective surgery on two different fingers of the right hand.

Both procedures, however, were performed on the same finger, according to a department report.

The hospital had been fined $50,000 in 2007 for errors in brain surgeries on three different patients and was reprimanded for a mistake in a cleft palate procedure last May.

In a letter to hospital CEO Timothy J. Babineau, MD, the department of health called the problem "frustrating" and said it "significantly damages the public's perception of safety and the credibility of RI Hospital's ability to consistently provide for safe surgical procedures."

In a statement, Babineau said the hospital remains "committed to decreasing the frequency of medical errors including wrong-site surgery."

Glenn Rothman, MD, chair of surgery for Banner Desert Medical Center in Mesa, Ariz., and a nationally quoted expert on the subject, said an error like the one at Rhode Island Hospital is "extremely hard to prevent" because the entire hand is dressed for surgery, and the structures are smaller and much closer together.

However, he said the overall incidence of wrong-site surgeries "appears to be unchanged, despite all measures introduced to prevent it."

The hospital's report of the error states that a nurse marked a straight line down the patient's right forearm to the wrist rather than directly on the fingers because she didn't know where, exactly, the incisions would be made and did not want to be reprimanded.

However, the surgeon did not verify the correct surgical procedures, including the site and side.

After performing both procedures on the same finger, other OR staff asked why the operation on the second finger had not been initiated. The surgeon checked with the family of the patient, and subsequently performed the surgery on the correct finger.

However, the team failed to conduct a mandatory "time out" -- a protocol for confirming several surgery-related factors -- between procedures, the report states.

On Oct. 26, the Department of Health issued the fine as well as the compliance order requiring every surgery at Rhode Island Hospital to be observed by a licensed clinical professional who isn't part of the surgery team and who is trained to observe surgical site markings and time-out procedures.

That monitoring must continue for at least a year, the report states.

It also requires that every operating room at the hospital be equipped with video and audio monitoring equipment within 45 days, and that every doctor be taped performing surgery at least twice every year.

The hospital must also shut down elective surgery for one day and conduct a mandatory training and review of the uniform surgical procedures with all surgical staff.

It also has to immediately adopt and implement the state's Uniform Surgical Safety Checklist and Standard Definition.

In the 2007 cases, neurosurgeons operated on the wrong part of the brain in three different patients.

And last May, according to a Department of Health report, a patient was scheduled for a right alveolar bone graft from the right hip to the right soft palate.

The surgeon started to operate on the left palate instead, potentially because a nurse documented the incorrect side on a written report, although the patient was marked correctly.

Rothman said the addition of cameras in the OR may do little to curb wrong-site surgeries.

"I'm not aware of any data that show that works," he said. "Would cameras in the cockpits of planes reduce pilot error?"

Rather, a revamping of "time-out" standards from the Joint Commission on Accreditation of Healthcare Organizations' Universal Protocol may be in order, he said.

They've been "diluted" to include multiple factors to assess during a time-out, while they used to focus solely on three principles -- correct patient, correct site, and correct surgery, Rothman said.

"You have to simplify your checks and balances in order to make them effective," he said. "If you're making people pay attention to more tasks, there's more opportunity for error."

He noted that there is not universal acceptance that the time-out policy as it stands "prevents or reduces errors."

The OR should also be more team-oriented, he said, with other staff feeling empowered to speak up if they notice a problem.

"Even the person who is lowest on the perceived totem pole of education and training in the room has the same responsibility to pay attention and to speak up if they have any concerns," Rothman said. "There's no reason a junior person can't recognize [a mistake], but the environment may be intimidating."

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